Special Commentary: Filling the Need in Rural Healthcare Requires Changing Licensing Standards of Advanced Healthcare Professionals

Abstract

Access to quality health care is a struggle in rural areas even after many years.[1]  The challenge of delivering quality healthcare can be daunting in rural areas with low population density, transportation issues, low public funding levels for services and programs, staff recruiting issues and fragmentation of resources.[2]  In 2016 there were 39.8 primary care physicians to 100,000 residents in rural areas compared to 53.3 primary care physicians per 100,000 residents in urban areas.[3] The stats in 2005 were 55 primary care physicians per 100,000 residents in rural areas and 72 primary care physicians per 100,000 residents in urban areas.[4] Comparing the two statistics shows that the number of primary care physicians have decreased in both rural and urban areas over the last 11 years.[5]Rural communities offer a more patient centered approach since physicians are able to offer more comprehensive care, yet the number of physicians continue to decrease.[6]  In 2018 a primary care shortage was defined as having only one primary care physician per 2,000 patients in a county.[7] At that time 13 percent of US patients lived in a county with a primary care shortage.

 Rural areas are not able to compete with the better financed urban hospitals in medical staff recruitment.[8]  Smaller rural hospitals were not prepared for the shift from inpatient to outpatient care leading to declining occupancy making for less revenue.[9] Similarly, small family practices are closing as aging physicians retire with nobody to take over the practice. [10] Other elements contributing to financial trouble are economic stagnation, underinsured or uninsured residents and many elderly patients.[11]

Medical education programs have tried to develop methods of filling the need for rural doctors.[12] One common method many programs use is to actively recruit medical students that have rural backgrounds as these persons are more likely to choose to settle in a rural area as opposed to an urban one after completing their training.[13]  This method started after a study done by the Future of Family Medicine (FMM) project committee found that students from rural areas have a sense of belonging and the need to give back to their communities.[14] The American Academy of Family Physicians agrees the best way to fill the rural doctor shortage is to increase the number of students from rural areas.[15] Additionally federal, state and private entities fund rural medical education in hopes of attracting other medical students.[16]  Another method medical schools use to encourage students to settle in rural areas is to include rotations in rural communities and curricular elements pertaining to rural medicine in medical school and residency to encourage students already interested in rural practice to pursue it further.[17]

The perception that pursuing family medicine is a less “intellectual” avenue has considerably influenced the number of students that choose rural medicine.[18]  With the cost of education growing there is also concern that practicing as a family doctor or rural doctor would not allow for student loans to be paid down quickly.[19] However there is another way to meet the health care needs of rural communities that does not rely on physicians opening medical practices in rural areas; increasing the number and scope of practice for non-physician providers. To this end, licensing standards and scopes of practice of non-physician advanced healthcare professionals should be changed to provide greater access to care in rural communities.

[1] Weisgrau, Sheldon MHS. Issues in Rural Health: Access, Hospital, and Reform.  Health Care Financing Review. Fall 1995. Volume 17, Number 1.

[2] Phillips, Charles PhD, MPH. McLeroy, Kenneth PhD. Health in Rural America: Remembering the Importance of Place. American Journal of Public Healthe. 94(10) 1661-1663 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448509/

[3] National Rural Health Association. About Rural Healthcare. https://www.ruralhealthweb.org/about-nhra/about-rural-health-care#targetThe%20patient-to-%20primary%20care,per%20100%2C000%20in%20urban%20areas.&targetText=There%20are%2030%20generalist%20

[4] National Organization of State Offices of Rural Health.  About Rural Health in America. https://norsorh.org/about-rural-health-in-america/

[5] Id.

[6] Id.

[7] Heath, Sara. Patient Care Access News. NPs, PAs could Reduce Primary Care Physician Shortage Nearly 70%. Retrieved from https://patientengagementhit.com/new/nps-pas-could-reduce-primary-care-physician-shortage-nearly70

[8] Weisgrau, Sheldon MHS. Issues in Rural Health: Access, Hospital, and Reform.  Health Care Financing Review. Fall 1995. Volume 17, Number 1.

[9] Id.

[10] Seigler, Kirk. National Public Radio. The Struggle to Hire and Keep Doctors in Rural Areas Means Patients go Without care. May 21, 2019. https://www.npr.org/sections/health-shots/2019/05/21/725118232/the-struggle-to-hire-and-keep-doctors-in-rural-areas-means-patients-go-without-care

[11] Id.

[12] American Academy of Family Physicians (AAFP). Keeping Physicians In Rural Practice. https://www.aafp.org/about/policies/all/rural-practice-paper-html.

[13] Id.

[14] Martin JC, e.a., & Committee, F.o.(2004: 2(suppl 1)). The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med, S3-32.

[15] Id.

[16] American Academy of Family Physicians. (AAFP) Keeping Physicians in Rural Practice. https://www.aafp.org/about/policies/all/rural-practice-paper.html.

[17] Id.

[18] Id.

[19] Id.